What You Should Know About Appealing Medicare Claims

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A Closer Look At Overpayment Regulations

Here is the evolution of the law that controls the conduct of the national recovery audit contractors and the claim processing contractors such as Palmetto GBA.

• In 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) (Pub. L. 108-173).

• Section 935 of the MMA amended Title XVIII of the Social Security Act to add a new paragraph (f) to section 1893 of the act.

• The Department of Health & Human Services (DHHS) expanded upon the rules in Section 1893(f) of the Social Security Act.

• The DHHS codified their expanded §1893(f) rules in the CMS Manual System as Pub 100-06 Medicare Financial Management, for the Centers for Medicare & Medicaid Services (CMS), Transmittal 141. This became effective on September 12, 2008.

• The DHHS refers to the Pub 100-06 rules regarding overpayments as Change Request 6183 (CR 6183).

• The rules in CR 6183 govern the conduct of the RACs (and the claim processing contractors) as the RACs’ attempt to recoup overpayments from providers.

Author(s): 
David Mullens, DPM, Esq.

   Several months later, you will receive a demand letter from the RAC stating the amount of the “overpayment” you must now repay to Medicare. Keep the envelopes containing all of the correspondence from Medicare. An ALJ will not let Medicare bully a provider who can prove the provider responded to Medicare within the statutory period of time — as proven by the postmark on the Medicare envelope — no matter what Medicare says.

   Read the demand letter very carefully. Note whether for each and every claim deemed to be an “overpayment,” the RAC has specifically listed the name of the patient, the date of the service and the procedure code(s) at issue. Also note that for each and every claim deemed to be an “overpayment,” the RAC should explain why the provider should not receive payment for the submitted item or procedure code, which is now considered to be an overpayment.

   In regard to procedure codes denied on the basis of medical necessity, the RAC should explain for each code why the provider should have known the services would not be covered. In regard to each procedure code now considered to be an overpayment, the RAC should explain why the provider was not found to be without fault in causing the overpayment.

What You Should Know About Making A Redetermination Appeal

   As soon as you receive the overpayment letter from the RAC, send a request for a redetermination appeal. Your redetermination appeal letter will include a demand for any of the aforementioned information not included in the RAC letter demanding repayment of overpayment. You will specifically list each missing piece of information on each patient and demand the carrier respond with that information. Send the redetermination appeal request to the address designated in the overpayment letter you receive. Be careful since several addresses are included in the overpayment letter.

   You can stop the recoupment process in its tracks by sending the request for a redetermination appeal within 30 days of the date you receive the demand for repayment of overpayment. Although interest on the demanded amount will continue to accrue, Medicare cannot take any recoupment from future Medicare earnings for the duration of the redetermination appeal as long as you appeal within the 30-day time limit.

   Keep the envelopes containing all of the correspondence from Medicare. If you do not have the capability to scan all documents into pdf files on your computer, keep two identical folders of documents regarding the overpayment dispute.

   The first folder will contain the original documents from Medicare along with copies of the final, signed letters you sent to Medicare. Do not use the first folder of documents for anything other than as a repository of original documents in the case. The second folder will contain exact duplicate copies of the documents in the first folder, but you are free to make notes anywhere on the second folder documents and use the second folder as your work folder. Believe me, you will be very sorry if you have to submit a scribbled-on document to a judge so you will be happy to have two sets.

How To File A Reconsideration Appeal

   When you receive the carrier’s redetermination response, which upholds the RAC determination, immediately send a request for a reconsideration appeal. If you have not received the answers to the due process questions cited in your letter to the carrier, repeat every single one of those questions to the QIC in your request for a reconsideration appeal.

   You should demand every missing piece of information required of the RAC and the claims processing contractor. You have a right to this information and the failure of the RAC and the claims processing contractor to provide the answers to these questions amounts to a denial of your due process rights.

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